eacs guidelines v11
TRANSCRIPT
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EACS Guidelinesv11.0
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HIV TREATMENT
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ONLY 2 CATEGORIES
Initial Combination Regimen for ART-naïve Adult PLWH
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NEW
Initial Combination Regimen for ART-naïve Adult PLWH
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ABC/3TC + RAL qd or bidTDF/FTC/EVG/cTAF/FTC/EVG/cABC/3TC +EFVABC/3TC + ATV/c or ATV/rABC/3TC + DRV/c or DRV/rTAF/FTC or TDF/FTC or TDF/3TC + ATV/c or ATV/rRAL 400 mg bid + DRV/c or DRV/r
Initial Combination Regimen for ART-naïve Adult PLWH
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If the person has acquired HIV while receiving PrEP: In this situation, change PrEP to a triple-drug ART regimen including a third drug with a high barrier to resistance (preferably DRV/b, DTG or BIC) plus two nucleoside analogues without interrupting antiretrovirals.
Initial Combination Regimen for ART-naïve Adult PLWH
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Switch Strategies for Virologically Suppressed Persons
NEW
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Switch Strategies for Virologically Suppressed Persons
3TC+ATV/R
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Virological FailureSection has been updated including new wording for treatment recommendations in the presence of resistance mutations
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Treatment of Pregnant Women Living with HIV or Women ConsideringPregnancy
“The decision of ART regimen should be discussed with the person and individualized taking into account tolerability, possible adherence issues, as well weighed against potential risk coming from ART exposure or suboptimal pharmacokinetics in pregnancy”
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Treatment of Pregnant Women Living with HIV or Women ConsideringPregnancy
NEW
NEW
NEW
NEW
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Treatment of Pregnant Women Living with HIV or Women ConsideringPregnancy
ATV, ZDV and LPV/r
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ART in TB/HIV Co-infection
NEW
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Pre-exposure Prophylaxis (PrEP)
Whole section has been updated
NEW
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Pre-exposure Prophylaxis (PrEP)
Whole section has been updated
NEW
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Acknowledgements
WAVE - Women Against Viruses in Europe. Justyna KowalskaGuidelines Chair: Georg Behrens & Guidelines Coordinator: Lene Ryom
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Drug-drug interactions Catia Marzolinifor the Drug-Drug interactions EACS Guidelines panel
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Part IIIDrug-drug interactions and other prescribing issues in PLWH • Drug-drug interactions between ARVs and non-ARVs• Drug-drug interactions between Analgesics and ARVs• Drug-drug interactions between Anticoagulants/Antiplatelet Agents and ARVs• Drug-drug interactions between Antidepressants and ARVs• Drug-drug interactions between Antihypertensives and ARVs• Drug-drug interactions between Anti-malarial Drugs and ARVs• Drug-drug interactions between Anti-tuberculosis Drugs and ARVs NEW• Drug-drug interactions between Anxiolytics and ARVs NEW• Drug-drug interactions between Bronchodilators (for COPD) and ARVs• Drug-drug interactions between Contraceptives and ARVs• Drug-drug interactions between Corticosteroids and ARVs• Drug-drug interactions between COVID-19 Therapies and ARVs NEW• Drug-drug interactions between Hormone Replacement Therapy (HRT) and ARVs NEW• Drug-drug interactions between Immunosuppressants (for SOT) and ARVs• Drug-drug interactions between Pulmonary Antihypertensives and ARVs• Drug-drug interactions between Viral Hepatitis Drugs and ARVs• Administration of ARVs in PLWH with Swallowing difficulties• Dose adjustment of ARVs for Impaired hepatic function• Dose adjustment of ARVs for Impaired renal function• Selected non-ARV drugs requiring dosing dosage adjustment in renal insufficiency• Prescribing in elderly PLWH• Selected top 10 drug classes to avoid in older PLWH• Dosage recommendations for hormone therapy when used at high doses for gender transitioning
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Major updates to DDI tables+ FOSTEMSAVIR : temsavir mainly metabolized by hydrolysis, contribution of CYP3A4(produg converted no inhibitory or inducing effects on CYPs or UGTsto temsavir) inhibition of BCRP, OATP1B1/3
è temsavir does mostly not impact the PK ofcomedications except BCRP/OATP substrates
è strong inhibitors of CYP3A4: no clinicallyrelevant increase in temsavir concentrations
è strong inducers of CYP3A4: contraindicated assubstantial reduction in temsavir concentrations
è moderate inducers of CYP3A4: no clinicallyrelevant reduction in temsavir concentrations
DDI between ARVs and non-ARVs
QT interval prolongation at supra-therapeutic doses
examples: statins, ethinylestradiol, grazoprevir
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Major updates to DDI tables+ CABOTEGRAVIR : metabolism by UGT1A1 (major), UGT1A9 (minor)
no inhibitory or inducing effects on CYPs or UGTsinhibition of OAT1/3
è cabotegravir does mostly not impactcomedications except sensitive OAT substrates
è strong inducers: contraindicated assubstantial reduction in cabotegravir levels
è divalent cations: similarly to other INSTIs,oral cabotegravir is subject to chelation
DDI between ARVs and non-ARVsOral administration
è strong inhibitors: minimal effect on cabotegravir concentrations
è moderate inducers: minimal effect oncabotegravir concentrations
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DDIs with oral vs im cabotegravir/rilpivirine
è moderate and strong inducers are contraindicatedwith cabotegravir/rilpivirine LA
Oral administration Intramuscular administration
• chelation with divalent cations• change in gastric pH• Inhibition/induction CYP/drug transporters
• chelation with divalent cations• change in gastric pH• Inhibition/induction CYP/drug transporters
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DDIs with COVID19 therapies
www.covid19-druginteractions.org
Dosing recommendations withlow dose dexamethasone
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Alignment with WHO HIV treatment guidelines releasedin July 2021
DDIs with Anti-tuberculosis Drugs
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Other updates to DDI tables
www.hiv-druginteractions.org www.hep-druginteractions.org
EACS tables are linked to DDIs websites and have been revised to include all updatesmade to the websites in the past year. >30 comedications were included to existing tables.
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AcknowledgementsEACS panel members
Liverpool HIV/HEP/COVID Drug interactionswebsite teamDavid Back Saye KhooSara Gibbons Daryl HodgeAlison Boyle Fiona MarraJasmine Martin Justin ChiongCatia Marzolini
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Prevention and Management of Co-morbiditiesGuidelines V11.0
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EACS Guidelines V11.0• Co-morbidities Guidelines largest section of the EACS Guidelines• 57 pages of guidance spanning 17 major themes• Incorporates principles of shared care• Challenges of COVID19
Frailty / Ageing Type 2 diabetes mellitus
Opioid addiction DyslipidaemiaCancer Lifestyle Interventions
Cardiovascular Disease
Hypertension
Renal disease Liver diseaseObesity / weight gain Sexual and
reproductive healthRespiratory disease TravelOrgan transplant Mental health and
cognitive impairmentBone health / vit D / fractures
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EACS Co-morbidities Guidelines V11.0Frailty / Ageing Type 2 diabetes mellitusOpioid addiction Dyslipidaemia
Cancer Lifestyle InterventionsCardiovascular Disease Hypertension
Renal disease Liver diseaseObesity / weight gain Sexual and reproductive healthRespiratory disease TravelOrgan transplant Mental health and cognitive
impairmentBone health / vit D / fractures
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EACS Co-morbidities Guidelines V11.0Frailty / Ageing Type 2 diabetes mellitusOpioid addiction Dyslipidaemia
Cancer Lifestyle InterventionsCardiovascular Disease Hypertension
Renal disease Liver diseaseObesity / weight gain Sexual and reproductive healthRespiratory disease TravelOrgan transplant Mental health and cognitive
impairmentBone health / vit D / fractures
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Mental Health – Anxiety Disorders
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EACS Co-morbidities Guidelines V11.0Frailty / Ageing Type 2 diabetes mellitusOpioid addiction Dyslipidaemia
Cancer Lifestyle InterventionsCardiovascular Disease Hypertension
Renal disease Liver diseaseObesity / weight gain Sexual and reproductive healthRespiratory disease TravelOrgan transplant Mental health and cognitive
impairmentBone health / vit D / fractures
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Diabetes mellitus
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EACS Co-morbidities Guidelines V11.0Frailty / Ageing Type 2 diabetes mellitusOpioid addiction Dyslipidaemia
Cancer Lifestyle InterventionsCardiovascular Disease Hypertension
Renal disease Liver diseaseObesity / weight gain Sexual and reproductive healthRespiratory disease TravelOrgan transplant Mental health and cognitive
impairmentBone health / vit D / fractures
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Treatment of dyslipidaemia – LDL goals
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EACS Co-morbidities Guidelines V11.0Frailty / Ageing Type 2 diabetes mellitusOpioid addiction Dyslipidaemia
Cancer Lifestyle InterventionsCardiovascular Disease Hypertension
Renal disease Liver diseaseObesity / weight gain Sexual and reproductive healthRespiratory disease TravelOrgan transplant Mental health and cognitive
impairmentBone health / vit D / fractures
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• Evolving area
• More detailed guidance
• Targeted treatment goals
• Lifestyle, behavioural, pharmacological and surgical management options
Obesity / Weight Gain
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EACS Co-morbidities Guidelines V11.0Frailty / Ageing Type 2 diabetes mellitusOpioid addiction Dyslipidaemia
Cancer Lifestyle InterventionsCardiovascular Disease Hypertension
Renal disease Liver diseaseObesity / weight gain Sexual and reproductive healthRespiratory disease TravelOrgan transplant Mental health and cognitive
impairmentBone health / vit D / fractures
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Approach to screening for Frailty
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AcknowledgementsSuccession planning:Goodbye and thanks to:- Manuel Battegay- Jens Lundgren- Neil Poulter
Welcome to:- Franck Boccara- Fatima Brañas- Susanne Dam Nielsen- Giada Sebastiani
Incoming Chair: Alan WinstonYoung Scientist: Aoife Cotter
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• Guidelines Chair and coordinator• Medical Secretariat• Members of the EACS guidelines panels- HIV Treatment- Drug-drug interactions- Viral Hepatitis Co-infections- Opportunistic Infections and COVID19- Paediatric HIV Treatment
• Governing Board
Acknowledgements
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Clinical Management and Treatment of Viral Hepatitis Co-infections in PLWH
Andri Rauch for the Viral Hepatitis Co-infections EACS guidelines panel
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Disclosures
ANDRI RAUCH
Research Support: GileadSpeaker’s Bureau: NoneBoard Member/Advisory Panel: MSD, Gilead, AbbvieStock/Shareholder: NoneConsultant: NoneEmployee: NoneOther: None
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§ Simplified HCV treatment option: - If pangenotypic regimens are foreseen, HCV genotype determination is
not mandatory before starting treatment
§ Treamtent of recently acquired Hepatitis C:- Immediate treatment recommended to reduce onward transmission1
§ HCV treatment options- Table with alternative treatment options was removed
§ HDV infection- Bulevirtide added as treatment option for HDV-infection
Summary of Changes
1 Boesecke et al, NEAT recommendations, AIDS 2020
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DAA treatment options
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Recently acquired HCV infection
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Thanks
New young scientist: Kathrin van Bremen, Bonn Germany
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Part VI Opportunistic Infections and COVID-19
Ole Kirk for the Opportunistic Infection EACS guidelines panel
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Changes• New section on COVID-19• Table on when to start ART in PLWH with OIs• Table on primary Prophylaxis of OIs According to Stage of Immunodeficiency
• Prophylaxis and treatment of Pneumocystis jirovecii Pneumonia (PcP)
• TB section• Minor revisions in text for individual OIs
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New COVID-19 section• NOT COVID treatment guidelines• Introduction• Management of COVID-19 in PLWH• Management of HIV infection while on treatment for COVID-19 and duringthe pandemic
• Management of long-term symptoms and sequelae of COVID-19
• Prophylaxis of COVID-19 - vaccines and monoclonal antibodies
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When to start ART & primary prophylaxis
Table on when to start ART in PLWH with OIs• Removal of CD4 threshold and of comment on CMV end organ disease
• Inclusion of comment on TB meningitis (delay of ART initiation for 4 weeks, but can be initiated within the first 2 weeks if CD4 < 50 (100) cells/μL)
Table on primary Prophylaxis of OIs According to Stage of Immunodeficiency• Inclusion of strategy for management of positive cryptococcal serum antigen and CD4 count <100 cells/µL
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Pneumocystis jirovecii Pneumonia
Secondary prophylaxis:• Can be interrupted when CD4 count >100 cells/µL and HIV-VL undetectable over 3 months
Treatment:• Wording changed regarding addition of caspofungin or other echinocandins to standard treatment for moderate-severe PcP: can be considered, but not mandatory
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Tuberculosis ITreatment for fully susceptible TB:• An alternative shorter regimen of rifapentine,isoniazid, pyrazinamide and moxifloxacin for 2 months, followed by rifapentine, isoniazidand moxifloxacin for 2 months can be used, if rifapentine is available
Reference to see Drug-drug Interactions between Anti-tuberculosis Drugs and ARVs
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Tuberculosis IIText for resistant TB revised (aligned with WHO guidelines from 2020)• definition of XDR-TB• all oral regimens for MDR-/ XDR-TB
• and shorter (6-12 months) courses in selected groups of MDR-/XDR-TB
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Other panels (HIV Treatment, Comorbidity and Drug-Drug Interactions), especially youngscientists Rosa De Miguel Buckley and Aoife Cotter
Acknowledgements
Guidelines Chair Georg Behrens & Guidelines Coordinator Lene Ryom
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Paediatric ART Panel
Alasdair Bamford for the EACS Peadiatric ART Panel
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https://penta-id.org/
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What to do if preferred option becomes available ?
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Additional sections
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Second line options
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Optimising NRTI backbone